Re-envisioning Fistula First in a Patient-Centered Culture

Abstract

SummaryThe main options for vascular access in hemodialysis patients are arteriovenous fistulas (AVFs), arteriovenous grafts, and tunneled cuffed central venous catheters. AVFs have the lowest complication rate and require the fewest interventions and lowest cost to maintain. There has been a dramatic national increase in prevalent AVFs among patients with ESRD in the United States driven, in part, by the Fistula First Breakthrough Initiative. The Fistula First Breakthrough Initiative has engaged stakeholders in the dialysis community to disseminate best practices and quality improvement activities to increase AVF prevalence in suitable candidates. In the pursuit of maximizing AVF placement and prevalence, less emphasis has been placed on the individual patient context. An AVF may not be the best access choice in a subset of patients, particularly those with poor long-term prognoses or comorbid chronic diseases with a short life expectancy, those patients more likely to die than to have their CKD progress to ESRD requiring dialysis, and those with vascular anatomy not amenable to successful AVF placement. Placement of an AVF in these patients subjects them to uncomfortable and likely unnecessary and/or unsuccessful surgeries at an expense, while doing little to improve their clinical outcome or their individual experience of care. AVF prevalence as a pay-for-performance measure without the appropriate case-mix adjustment may penalize providers for accepting higher-risk patients. Although a functioning AVF that provides reliable hemodialysis remains the gold standard for vascular access for most patients, it may not be the most suitable option for every patient.

Vascular Access Choice in Incident Hemodialysis Patients

“…Accordingly, practice and reimbursement guidelines should potentially allow for more flexibility, possibly including an indicator of vascular access suitability and likelihood of success. 18 In our model, age, sex, and diabetes status serve as predictors of both the probability of AV fistula failure and overall mortality. Because each of these factors has a strong effect on survival and cost differences among different access types, it is likely that better predictive models for both successful AV fistula creation and mortality could further assist in determining the optimum access choice for patients on hemodialysis.…”

Outcomes of Vascular Access Care and Surgery Managed by Interventional Nephrologists: A Twelve-Year Experience

“…Optimizing VA outcomes requires an appropriate choice of VA type and surgical strategy, on the basis of patient's characteristics and anatomy of vessels [32,33] . Substantial comorbidities, older age and female gender are 118 recognized risk factors of primary fistula failure [11,12,15,18] .…”

Fistula First Initiative: Historical Impact on Vascular Access Practice Patterns and Influence on Future Vascular Access Care

“…Furthermore, the ability to deliver adequate dialysis therapy with prosthetic conduits, such polytetrafluoroethylene grafts (AVG) [8–10], and central venous catheters (CVC) in the upper extremity system [11–13] also expanded the pool of dialysis patients eligible for treatment. The number of surgical vascular accesses created each year has continued to increase with 500,000 created in 2007 [14]. However, the cumulative effect of the increase in hemodialysis patients in the U.S. has been the proportion of autologous AVFs use decreased and CVCs and AVGs increased in the late 1990’s and early 2000’s.…”